The African Background of Medical SciencePosted: Thursday, July 19, 2001

January 05 2000

A special feature by Charles Finch, M.D. Chairman, Dept. of International Medicine, The Morehouse School of Medicine

It has become increasingly clear that traditional African cultures and civilizations knew and accomplished much more than has traditionally been assumed. Even after we've "restored" ancient Egypt - a civilization that was the fountainhead of science - to its true and natural place on African soil as an African creation, there is yet a profound reluctance to admit that Africa contributed anything of substance to world science.

In this article, the author hopes to show that traditional African physicians evolved effective - even sophisticated - diagnostic and therapeutic modalities in medicine which belie the notion that Africa was without a medical science.

Just as any discussion of the achievements of Western medicine harkens back to Hippocrates and Galen, so any discussion of African medical achievements harkens back to ancient Egypt. Newsome, among others, has shown what a debt Greek medicine owed to the priest-physicians of Egypt.(1) Not only was the most important Greek healing deity, Asclepios, identified with the legendary Egyptian physician-architect-aphorist Imhotep but Hippocratic therapeutics had direct antecedents in Egyptian medicine. The city-state of Athens used to import Egyptian physicians, as did most of the kingdoms of the Near East, and in the Odyssey, Homer says, "In medical knowledge, Egypt leaves the rest of the world behind."(2)

Like all African medicine, Egyptian medicine has baffled scholars because of the complete interpenetration of "magico-spiritual" and "rational" elements. Mostly, this magico-spiritual aspect has been downplayed or belittled. However, at least one researcher concedes that healing, being a complicated psychic as well as physical process, may be amenable to an approach that touches that hidden area of the psyche beyond the reach of rational therapy.(3) Even modern medicine concedes that as much as 60% of illness has a psychic base and indeed, the well-known "placebo" effect of modern pharmaco-medicine arises from this.(4) We moderns like to deride this magico-spiritual medicine but it can and does produce startling results that we do not understand.

The Egyptians were writing medical textbooks as early as 5,000 years ago.(5) This indicates not only a mature civilization but also a long period of medical development. Out of the hundreds and thousands of medical papyri that must have been written, only 10 have come down to us, the most important being the Ebers and Edwin Smith Papyri. These 10 papyri form the basis of most of what Egyptologists know about Egyptian medicine. It has been affirmed, however, that much of the training and instruction of the healing priests must have been orally transmitted, as it is in the rest of Africa.(6) It is likely, therefore, that we have only a partial grasp of the true scope of Egyptian medical knowledge. Moreover, like their counterparts in the rest of Africa, the Egyptian priest-physicians often kept their best knowledge secret.

Egyptian physicians were instructed in the "per ankh" or "house of life" which served as a university, library, medical school, clinic, temple, and seminary. The numerous Greek philosophers who studied in Egypt, such as Pythagorous, Thales, and Plato, must have spent their time in a per ankh. In these centers of learning, there was no sharp demarcation between the fields of study; religion, philosophy, science, astronomy, mathematics, music, and hieroglyphics were all part of the same species of knowledge and were reflected in one another.

It is of interest that the Egyptians were alone among the nations of antiquity in the development of specialty medicine. In the Old Kingdom, the diseases of each organ were under the care of a specialist. In the later epochs, the specialists disappeared as the Egyptian physician began to function as a generalist. However, during Ptolemaic times, specialization came back into the vogue, probably as a result of renewed interest in the archaic culture. Not until the 20th century did anything comparable in the sphere of medicine develop. Contemporary doctors are accustomed to believing that modern specialty medicine resulted from a progressive evolution of medical techniques and knowledge, hardly realizing that it is a throw back to the earliest form of Egyptian medical practice.

A study of ancient Egyptian diagnostic methods reads disconcertingly like a modern textbook on physical diagnosis. A physician summoned to examine a patient would begin with a careful appraisal of the patient's general appearance. This would be followed by a series of questions to elicit a description of the complaint. The color of the face and eyes, the quality of nasal secretions, the presence of perspiration, the stiffness of the limbs or abdomen, and the condition of the skin were all carefully noted. The physician was also at pains to take cognizance of the smell of the body, sweat, breath, and wounds. The urine and feces were inspected, the pulse palpated and measured, and the abdomen, swellings, and wounds probed and palpated. The pulse taking is worth noting because it indicates that the Egyptians knew of its circulatory and hemodynamic significance. Percussion of the abdomen and chest was performed and certain functional tests we still use today were done, i.e., the coughing test for hernia detection; the extension-flexion maneuver of the legs to test for a dislocated lumbar vertebra. Sometimes, the case required more than one consultation and the physician might, as is done today, embark on a "therapeutic trial" to ascertain the efficacy of treatment. It also seems that the Egyptians practiced a form of socialized medicine. All physicians were employees of the state and medical care was available to everyone.(7)

The extant medical papyri show us that the Egyptians had quite an extensive knowledge of anatomy and physiology. They understood the importance of pulsation and - 4500 years before Harvey - knew something of the structure and function of the cardiovascular system. They knew that the heart was the center of this system, had names for all the major vessels, knew the relation between heart and lung, and knew the distribution of the vessels through the limbs.(8) They had names for the brain and meninges (the covering of the brain and spinal cord) and also seem to have known the relation between the nervous system and voluntary movements. In addition, the ureters (the connections between the kidneys and the bladder) were known and named. Most writers state that the Egyptians’ anatomical knowledge while relatively sophisticated, was, by modern standards, rudimentary. They aver, for example, that the Egyptians attached no special significance to the brain.(9) But at least one researcher, utilizing sources entirely different from the papyri, contradicts this notion, asserting that their knowledge of neuroanatomy in particular was as detailed and advanced as that in modern times.(10)

The Egyptians were well-versed in many pathological syndromes. The identification of a disease syndrome necessitates acute and painstaking clinical observation, often over many years, and many of the ones described in the medical papyri are known today. Egyptian physicians understood the origin of paraplegia and paralysis from spinal cord injuries and recognized the traumatic origin of neurological symptoms such as deafness, urinary incontinence, and priapism. They described many syndromes of cardiac origin. They knew that excess blood in the heart and lungs was pathological which is consistent with what we know about congestive heart failure today. They also seem to have recognized the significance of heart palpitations and arrhythmias and gave a rather precise definition of angina pectoris:

"If thou examinest a man for illness in his cardia and he has pains in his arms, in his breast, and on one side of his cardia...it is death threatening him."(ll)

The modern description of angina pectoris can hardly improve upon this. The phrase seen in the Ebers Papyrus, "belly too narrow for food," seems to indicate an esophageal or stomach stricture perhaps from an inflammatory or ulcerating process. Egyptian physicians also knew that a weak heart adversely affected the liver, calling to mind the pathological enlargement of the liver which we know to be due to heart failure. Faintness due to a "dumb heart" was described which seems to be an allusion to a Stokes-Adams attack.(12) It is evident that the ancient Egyptian physicians had a fundamental grasp of the pathophysiology of many of the syndromes we know today.

Perhaps the most remarkable document among the medical papyri is the surgical Edwin Smith Papyrus, a compendium of Egyptian anatomical knowledge and surgical methods. It is in this papyrus that the remarkable descriptions of the traumatic surgical lesions and their treatment are found. We also find that the priest-physicians also recognized the signs and symptoms of sciatica, the sharp pain radiating down the leg caused by nerve compression in the lower spinal cord. Like many other peoples in Africa and the rest of the world, the Egyptians practiced trephination. (13) This operation, the forerunner of neurosurgery, involves boring a hole through the skull to the outer covering of the brain. This was done to remove fragments from a skull fracture compressing the brain, to treat epilepsy, or to relieve chronic headache. Today in Africa there are people who have undergone this operation with no apparent ill effects and there are skulls from ancient Egyptian graves with definite signs of healing around the trephination site so it is clear that patients survived this operation.

As is seen very commonly in Africa, there was a separate guild of bonesetters in Egypt who treated fractures and dislocations. These specialists devised a completely effective method for reducing collar bone fractures which Hippocrates later used. (14) The Edwin Smith Papyrus also describes maneuvers for reducing dislocated jaws and shoulders. Long bone fractures were immobilized with tight splints and nasal fractures were treated by the insertion of stiff nasal packings into the affected nostril, a method also used today for uncomplicated nasal fractures.

The Egyptians had perhaps 3-4 thousand years of experience dissecting and bandaging mummies and this must have had beneficial effects on surgical technique. They had an array of knives and scalpels to excise tumors and drain abscesses. They used red-hot metal instruments to seal off bleeding points and closed clean wounds with sutures or adhesive tape. They were unsurpassed as "bandagists" and used their techniques to control bleeding. Fresh meat was also used to stop oozing hemorrhage from surgical wounds. Like the ancient Chinese, they used molds from bread or cereals to treat wound infections. Modern penicillin was extracted from a mold so the priest-physicians must also have been aware of its bacteriacidal properties. (15)

Like all African peoples, the Egyptians had a large materia medica, using as many as 1000 animal, plant, and mineral products in the treatment of illness. Night blindness, caused by vitamin A deficiency, was treated with ox livers, known to be rich in vitamin A. Poppy extract - the source of opium - was used to treat colicky babies. Modern physicians use paregoric - whose active ingredient is opium - for exactly the same purpose. Patients with scurvy - caused by vitamin C deficiency - were fed onions, a known source of vitamin C. Castor seeds, the source of castor oil, were used to make cathartic preparations. Mandrake and henbane, sources of belladonna alkaloids, were also known and used. The belladonnas possess properties that stimulate the heart, decrease stomach motility, dilate the pupils, and cause sedation. The Egyptians dispensed their prescriptions as pills, enemas, suppositories, infusions, and elixirs in accurate, standardized doses causing some to wonder if they had separate pharmacies and pharmacists. (16)

The Egyptians were also quite knowledgeable in handling obstetric and gynecological problems. They knew and treated uterine prolapse. They had means of inducing abortions and preventing conception. They even had an effective pregnancy test! A sample of a woman's urine was sprinkled on growing cereals; if the cereals did not grow the woman was considered not pregnant; if they did grow she was declared pregnant. Modern experiments have shown that a pregnant woman's urine has a permissive effect on the growth of barley in about 40% of the case, demonstrating that there must have been some validity in the world's first pregnancy test. (17)

Our glimpse of the medical system of this ancient African civilization shows that it deserves its reputation as the best and most advanced of antiquity. Indeed, medicine as we know it today began in Egypt rather than Greece. A study of other African systems of medicine is more problematic, however, because of the absence of surviving written records. Thus, most of what we know comes from the testimony of European missionaries whose contemptuous view of traditional culture was most pointed when writing about traditional medical practices. Nonetheless, it can be shown that the best of the traditional healers in various parts of Africa acquired a startling level of proficiency and, contrary to contemporary opinion, were not without a medical science.

It is pertinent to remember that Africa has been subjected to centuries of almost continuous political, social, and cultural disruption and that - among cultures that rely heavily on oral transmission of knowledge - a tremendous amount of knowledge has been lost. Thus, the state of traditional medicine today does not reflect the best of what the traditional doctors knew and surviving fragments of eye-witness reports - as shall be shown - indicate that they knew quite a lot.

Like ancient Egypt, all traditional African cultures had a magico-spiritual conception of disease. Thus in this setting, moral, social, or spiritual transgressions are likely to lead to illness because they create both individual and communal disharmony. Without the psycho-spiritual cure - without re-establishing this sensitive harmony - the medicinal cure is considered useless. The traditional practitioner is intimately acquainted with the psychic, social, and cultural nuances of his people and more than one commentator has acknowledged that the traditional doctor is often an expert psychotherapist, achieving results with his patients that conventional Western psychotherapy cannot.

Though there is no single paradigm of medical practice that applies to all of Africa, many of the essential features of the various traditional systems are comparable and even identical. Among the Mano of Liberia, for example, all children's diseases, all obstetrics, all of the "everyday" complaints are handled by women, particularly the elderly women; surgery, bonesetting, and special diagnostic and therapeutic problems are handled almost exclusively by men. This is a pattern that repeats itself throughout Africa.

The approach to the patient can vary in different parts of Africa. In some societies, where the doctor is credited with paranormal insight, the physician may arrive at a diagnosis and prescribe treatment without questioning or examining the patient since he is supposed to know what is wrong by virtue of his special powers. However, other traditional doctors affect an approach toward physical diagnosis closer to our own:

"Many Western-trained doctors concede that the traditional medical experts have a profound knowledge of the human body and anatomy. This is demonstrated by a usually careful diagnosis beginning with a history of the disease followed by a thorough physical examination...He palpates the different parts and looks for tender spots. He feels the beating of the heart, the position of the inner organs, checks the eyes and ears, and smells the mouth for bad breath." (18)

Most commentators have disparaged the traditional doctor's knowledge of anatomy and physiology. The Mano, however, have names for most of the major organs and know the difference between normal and abnormal anatomy. (19) Another author notes that the Banyoro of Uganda, renowned in the last century for their surgical skill, had a wide knowledge of anatomy. (20) A Hausa maneuver to test for impotence has been described:

"An individual is stripped and placed on a mat lying on his back. A pin or thorn is lightly rubbed over the inside of his thigh. If the scrotum or testicles do not move, the individual is considered impotent."

There is a physiological basis for this procedure. The maneuver in effect tests the cremasteric reflex. The cremaster muscle contracts and pulls the testicles upward on stimulation of the inside of the thigh. (21) This passage belies the notion that African doctors were without a knowledge of some of the body's physiological processes. Moreover, Mano physicians - reputedly without an understanding of the body's cardiovascular system - knew that the conditions of anasarca and ascites were due to fluid overload and treated accordingly with diuretic preparations. These interesting fragments do not by themselves admit of a sophisticated anatomical or physiological knowledge but they hint at a greater degree of knowledge - perhaps in past ages - than has hitherto been recognized.

Some case studies of cultures in east-central Africa have brought to light some remarkable evidence revealing the presence of scientific medicine there. The practice of carrying out autopsies on patients dying of unknown causes among the Banyoro of Uganda and the Likundu of Central Africa has been described. Almost always these were carried out to detect a possible witchcraft etiology but may well have contributed to a more extensive knowledge of anatomy than previously supposed:

"The procedures for autopsying bodies under the Likundu culture have been reviewed, not for the purpose of considering the beliefs that impelled such procedures but to indicate that in some areas autopsies were frequently carried out and that they involved searching in the body, a search which might be casual and superficial but which in other cases might be prolonged and exacting and involved opening up and examining a variety of organs. These are precisely the circumstances under which considerable knowledge of anatomy and pathology could be acquired by persons who, for any purpose, might wish to do so. (22)

Further, there is a report of a Banyoro king who commissioned a traditional doctor to travel around the countryside to investigate, describe, and search for a cure for sleeping sickness, which was ravaging the country at the time.(23) This clearly indicates that a spirit of clinical investigation did exist among Banyoro physicians and probably among other traditional practitioners as well. In many parts of Africa, treatments were devised for new diseases like venereal disease and scrofula that were imported into Africa and this would presuppose some form of clinical investigation and experimentation.

In some parts of Africa, it would seem that the traditional doctor had a firm grasp of some fundamental public health principles. In Liberia, the Mano developed an admirable quarantine system for smallpox. They were well aware of its contagiousness and set aside a "sick bush" for affected patients. This was situated well away from the village and the patient was attended by only one person; no one else was allowed to approach the area. The patient was put on a careful diet and was rubbed with topical anesthetic medications to prevent scratching which could lead to infection. When the illness ran its course, the area wasburned. The "sick-bush" approach would do a modern epidemiologist proud. Of further interest is the centuries-old practice of small-pox variolation which is carried out all over Africa. During an epidemic, material from the pustule of a sick person is scratched into the skin of unaffected persons with a thorn. In the majority of instances, there is no reaction and the persons inoculated are protected against smallpox. In some cases, the inoculation will produce a mild, non-fatal form of the disease which will also confer permanent immunity.(24) Centuries before Jenner, Africans had devised an effective vaccination method against smallpox.

In the area of surgery, the best evidence indicates that some African surgeons attained a level of skill comparable, and in some respects superior, to that of Western surgeons up to the 20th century. As in ancient Egypt, the bonesetter guilds were separate from those of the traditional doctors and were renowned for their skill. Some commentators, observing the bonesetters of today, feel that this reputation was somewhat inflated and the bonesetters' results were less than optimum by Western standards.(25) Yet other reports cite techniques that led tohighly satisfactory results. Mano bonesetters treated a patient with a thigh fracture by placing him in the loft of a house allowing the affected leg to dangle free with a heavy stone attached. This was a very effective traction method and once the fracture was reduced, it was immobilized with a tight splint. (26) In addition, the patient was encouraged to exercise a fractured leg and we know today that new bone is laid down more rapidly over the fracture site when there is some exercise of the limb. Bonesetters in other parts of Africa would dig a deep pit for the purpose of exercising traction on a fractured limb and in East Africa, the bonesetters reduced fractures and dislocations by manual manipulation and traction. These examples indicate that the bonesetters' reputation was not entirely undeserved.

In many areas, especially among warlike peoples, the traditional physician was particularly adept in treating traumatic wounds. One report describes the treatment of an open wound by the following method: plant juices with anti-septic properties were squeezed into the open wound, a red hot metal tip was used to cauterize bleeding points and burn away damaged tissue, the wound edges were closed with a tough thorn, an awl, and fibrous suture and a fiber mat was wrapped tightly around the wound to prevent bleeding. The wound was never closed until the bleeding had been stopped. (27) In another documented instance, a native surgeon successfully resected part of a patient's lung to remove a penetrating arrow-head.(28) In the Congo, a native surgeon was seen using stiff elephant hairs to probe for and successfully remove a bullet.(29) In Nigeria, a man who had had his abdomen ripped open by an elephant was treated by the doctor by replacing the intestines in the abdominal cavity, securing them in place with a calabash covering, and finally suturing together the overlying abdominal wall and skin. Not only did the man recover but was soon back working on a road gang. (30) In the testimony of one author:

"Witch doctors of many tribes perform operations for cataract. They squeeze the juice from the leaves of an alkaloid-containing plant directly into the eye to desensitize it, then push the cataract aside with a sharp stick. A surprising number of these cases turn out successfully."(31)

In East Africa, Masai surgeons were known to successfully treat pleurisy and pneumonitis by creating a partial collapse of the lung by drilling holes into the chest of the sufferer.(32)

It is pertinent to now consider one of the most remarkable examples of African surgery ever documented. This is an eye-witness account by a missionary doctor named Felkin of a Caesarean section performed by a Banyoro surgeon in Uganda in 1879:

"The patient was a healthy-looking primipara (lst pregnancy) of about twenty years of age and she lay on an inclined bed, the head of which rested against the side of the hut. She was half-intoxicated with banana wine, was quite naked and was tied down to the bed by bands of bark cloth over the thorax and thighs. Her ankles were held by a man...while another man stood on her right steadying her abdomen...the surgeon was standing on her left side holding the knife aloft and muttering an incantation. He then washed his hands and the patient's abdomen first with banana wine and then water. The surgeon made a quick cut upwards from just above the pubis to just below the umbilicus severing the whole abdominal wall and uterus so that amniotic fluid escaped. Some bleeding points in the abdominal wall were touched with red hot irons. The surgeon completed the uterine incision, the assistant helping by holding up the sides of the abdominal wall with his hand and hooking two fingers into the uterus. The child was removed, the cord cut, and the child was handed to an assistant." (33)

The report goes on to say that the surgeon squeezed the uterus until it contracted, dilated the cervix from inside with his fingers (to allow post-partum blood to escape), removed clots and the placenta from the uterus, and then sparingly used red hot irons to seal the bleeding points. A porous mat was tightly secured over the wound and the patient turned over to the edge of the bed to permit drainage of any remaining fluid. The peritoneum, the abdominal wall, and the skin were approximated back together and secured with seven sharp spikes. A root paste was applied over the wound and a bandage of cloth was tightly wrapped around it. Within six days, all the spikes were removed. Felkin observed the patient for 11 days and when he left, mother and child were alive and well. (34)

In Scotland, Lister had pioneered antiseptic surgery just two years prior to this event but universal application of his methods in the operating rooms of Europe was still years away. Caesarean sections were performed only under the most desperate circumstances and only to save the life of the infant. A Caesarean section to save the lives of both mother and child was unheard of in Europe nor are there records of such a procedure among the great civilizations of antiquity. As one commentator has said:

"The whole conduct of the operation as Felkin described it suggests a skilled, long-practiced surgical team at work conducting a well-tried and familiar operation with smooth efficiency and unhurried skill...Lister's team in London could hardly have performed with greater smoothness." (35)

Not only did the surgeon understand the sophisticated concepts of anesthesia and antisepsis but also demonstrated advanced surgical technique. In his sparing use of the cautery iron, for example, he showed that he knew tissue damage could result from its overuse. The operation was without question a landmark, reflecting the best in African surgery.

African midwives possessed a good understanding of some fundamental obstetric and pediatric principles. Mano midwives pulled repeatedly at the breasts of women in labor, a maneuver which induces the release of oxytocin - a stimulator of uterine contractions - from the pituitary gland. They sometimes took laboring mothers upon their backs walking around with and shaking them. This undoubtedly had the effect of causing the cervix to dilate and the head to engage, thus facilitating labor.(36) Some Bantu midwives were known to use Indian hemp during labor for its sedative properties. Newborn babes and infants were taken and exposed to the sun for a period each day "to make them strong." One author attributed the rare occurrence of rickets among Mano children to this practice.(37) In addition, these women healers recognized the causes of malnutrition and retarded development, putting such children on special diets high in vitamins and carbohydrates with favorable results.(38)

Traditional African cultures have an abundant materia medica. The Zulus, for example are reputed to know the medicinal uses of some 700 plants. (39) Ouabain, capsicum, physostigmine, kola, and calabar beans are just a few of the substances from the African materia medica that have made their way into the Western pharmacopeia.(40) The traditional midwives often have drugs that can induce abortion in the first three months of pregnancy and in Uganda, in an area where there is a high incidence of dystocia (retarded labor), the midwives have preparations which stimulate uterine contractions. "Fever-leaf" is used all over Africa to treat the recurring fevers of malaria. Certain Bantu-speaking peoples use the bark of Salix capensis (willow) to treat the musculoskeletal complaints of rheumatism.(41) This family of plants yields salicylic acid, the active ingredient in aspirin, a sovereign remedy the world over for musculoskeletal pains. Kaolin, the active ingredient in Kaopectate is used in Mali to combat diarrhea. Caffeine-containing kola nuts are chewed all over Africa for their stimulating and fatigue-combating properties. To combat snakebite, plants containing ouabain and strichnine are used. The former is a heart stimulant and therefore useful against cardiotoxic venoms and the latter is a nerve tonic, useful against neurotoxic venoms. In

Nigeria in 1969, the rootbark Annona senegalensis was found to possess strong anti-cancer properties.(42) Even more recently in 1979, herbal preparations that were used in Nigeria to treat skin infections were found have definite bacteriocidal activity against gram-positive bacteria, the very organisms that cause skin infections. (43) There was an interesting case in 1925 of an eminent Nigerian in England who was suffering from severe psychotic episodes not amenable to treatment by English doctors. A traditional doctor from Nigeria was summoned who was able to relieve the patient of his symptoms with decoctions made from a rauwolfia root. (44) The Rauwolfia family of plants is the source of modern-day Reserpine, first used as a major tranquilizer to treat severe psychosis but now used mainly as an antihypertensive medication.

The list of effective drugs in the African pharmocopeia is too extensive to elucidate here but suffice to say that traditional doctors in Africa had and have effective remedies against intestinal parasites, vomiting, skin ulcers, rashes, catarrh, convulsions, tumors, venereal disease, bronchitis, conjunctivitis, urethral stricture and many other complaints.

There are at least two documented instances of Europeans benefiting from the ministrations of the traditional physician. In the last century, a Bushman doctor cured a European woman dying of sepsis that the European doctor could not treat. In Swaziland, a European doctor, dying of dysentery, was cured by a native physician. (45) Moreover, the native physicians in this area were so skilled at treating Typhoid Fever that the European doctors used their decoctions for the same purpose.

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This article has attempted to show that the traditional doctors of Africa from the earliest times had a high level of medical and surgical skill, certainly much more than they have been given credit for. It is to be hoped that more substantive and careful investigations will be carried out among the traditional healers of Africa before Western-style medicine supplants them entirely.

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